Position Summary:

This position is responsible for maintaining routine auditing functions and providing feedback on departmental activities, to assure compliance with all health plan and regulatory agencies, including CMS, DMHC, and DHS. This position includes the responsibility for routine hospital and professional audits, complex audits on individual or random, training and focused claims to identify exceptions to established claims adjudication requirements for claims processing, payment and procedural accuracy. In addition, this position is responsible to assist with eligibility identify (e.g. COB, ESRD) and Letters of Agreements as required. To maintain in strict confidence, all member, provider and Health Plan information to which Claims Auditing Specialist has access.

Essential Duties and Responsibilities include the following:

• Performs routine and complex audits on individual, random, trainee and focused claims to identify exceptions to established claims adjudication requirements for both Pre-EOB and post payment.
• Perform 1st level audit based on reports and run Virtual Examiner Reports prior to each check run.
• Researches claim processing problems and errors to determine their origin and appropriate resolution.
• Researches member activity to identify Coordination of Benefits, Third Party Liability, Out-of-Area and Workers’ Compensation as identified through member admissions, authorization process or claims activity
• Notify management immediately if any report processing deadlines cannot be met.
• Identify, proactively through auditing and internal reporting, negative and positive trends and initiate recommendations for change
• Analyze data processing reports and make necessary corrections or adjustments
• Assist with training of claims adjudication staff as needed
• Assist manager with follow-up on any problems or questions related to the audit results
• Other duties as assigned

Education and/or Experience

• High School graduation.
• Possess strong knowledge of CPT, ICD, HCPCS, DRG coding and claims adjudication for hospital and professional claims.
• Knowledge of medical terminology.
• Prefer 5 years previous experience with adjudication all types of claims.
• Basic level proficiency with Microsoft Office applications including Word, Excel, PowerPoint.

The pay range for this position at commencement of employment is expected to be between $20 per hour to $25 per hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

Job Type: Full-time

Pay: $20.00 - $25.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Work setting:

• In-person
• Office

People with a criminal record are encouraged to apply

Ability to Relocate:

• West Covina, CA 91790: Relocate before starting work (Required)

Work Location: In person